An Emerging Treatment for Common Symptoms in Older Adults Kevin H

CLINICAL INVESTIGATION

Cannabis: An Emerging Treatment for Common Symptoms in Older Adults Kevin H. Yang, BS,*a Christopher N. Kaufmann, PhD, MHS,*a Reva Nafsu, LVN,* Ella T. Lifset,* † Khai Nguyen, MD, MHS,* Michelle Sexton, ND, Benjamin H. Han, MD, MPH,* ‡ Arum Kim, MD, and Alison A. Moore, MD, MPH*

friends knew, and 41% reported their healthcare provider BACKGROUND/OBJECTIVES: Use of cannabis is increas- knowing. Sixty-one percent used cannabis for the first time as ing in a variety of populations in the United States; however, older adults (aged ≥61 years), and these users overall engaged few investigations about how and for what reasons cannabis in less risky use patterns (e.g., more likely to use for medical is used in older populations exist. purposes, less likely to consume via smoking). DESIGN: Anonymous survey. CONCLUSION: Most older adults in the sample initi- SETTING: Geriatrics clinic. ated cannabis use after the age of 60 years and used it PARTICIPANTS: A total of 568 adults 65 years and older. primarily for medical purposes to treat pain, sleep disturbance, anxiety, and/or depression. Cannabis use by INTERVENTION: Not applicable. older adults is likely to increase due to medical need, MEASUREMENTS: Survey assessing characteristics of favorable legalization, and attitudes. JAmGeriatrSoc cannabis use. 69:91-97, 2021. RESULTS: Approximately 15% (N = 83) of survey respon- ders reported using cannabis within the past 3 years. Half Keywords: cannabis; patient care; medical cannabis; use (53%) reported using cannabis regularly on a daily or weekly patterns basis, and reported using cannabidiol-only products (46%). The majority (78%) used cannabis for medical purposes only, with the most common targeted conditions/symptoms being pain/arthritis (73%), sleep disturbance (29%), anxiety (24%), and depression (17%). Just over three-quarters reported cannabis “somewhat” or “extremely” helpful in managing one of these conditions, with few adverse effects. Just over half INTRODUCTION obtained cannabis via a dispensary, and lotions (35%), tinctures (35%), and smoking (30%) were the most common here is unprecedented interest in the United States in administration forms. Most indicated family members (94%) T the potential health benefits of cannabis. As of 2020, knew about their cannabis use, about half reported their 33 states have enacted recreational or medical cannabis legislation, which mirrors changing perspectives about cannabis use. For example, support for cannabis legalization has increased from 12% of Americans in 1969 to 67% in From the *Division of Geriatrics and Gerontology, Department of 1 2 Medicine, University of California, San Diego, La Jolla, California; 2019. With the enactment of the Farm Bill in 2019, † Department of Anesthesiology, University of California, San Diego, La hemp-derived cannabidiol (CBD) products, which contain ‡ Jolla, California; and the Division of Geriatric Medicine and Palliative less than 3% of the psychoactive component tetrahydrocan- Care, Department of Medicine, New York University School of Medicine, nabinol (THC), have become more available throughout New York, New York. the country, providing greater access to cannabis for Address correspondence to Christopher N. Kaufmann, PhD, MHS, Division patients. of Geriatrics and Gerontology, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, Mail code: 0665, La Jolla, CA There is also some evidence that cannabis is useful in 3-6 92093. E-mail: [email protected] addressing chronic medical conditions. The National aJoint first authors. Academies of the Sciences, Engineering, and Medicine pub- Previous Presentation: This study was presented at the American Geriatrics lished an extensive review in 2017 of the health effects of Society 2020 Meeting. cannabis, finding empirical evidence for cannabis reducing DOI: 10.1111/jgs.16833 symptoms ranging from pain, spasticity, tremor, nausea,

Table 1. Demographic Characteristics of Cannabis Users

Total Use between 6 mo and 3 y ago Use within previous 6 mo Characteristic (N = 83) (N = 27) (N = 56)

Age, y <65 2 (2) 0 (0) 2 (4) 65–74 31 (37) 10 (37) 21 (38) 75–84 35 (42) 11 (41) 24 (43) ≥85 15 (18) 6 (22) 9 (16) Sex Female 50 (60) 19 (70) 31 (55) Male 33 (40) 8 (30) 25 (45) Race/ethnicity Non-Hispanic White 76 (92) 25 (93) 51 (91) Non-Hispanic Black 1 (1) 1 (4) 0 (0) Hispanic 5 (6) 1 (4) 4 (7) Non-Hispanic Asian 1 (1) 0 (0) 1 (2) Relationship status Married or long-term partner 48 (58) 12 (44) 36 (64) Widowed 20 (24) 9 (33) 11 (20) Divorced/separated 12 (14) 6 (22) 6 (11) Single, never married 3 (4) 0 (0) 3 (5) Education High school or less 9 (11) 3 (11) 6 (11) Some/completed college degree 35 (43) 15 (56) 20 (37) Graduate and/or advanced degree 37 (46) 9 (33) 28 (52)

Note: Data are given as number (percentage) of each group. Percentages correspond to column totals. There were no statistical differences across groups.

and, to some extent, sleep.7 For example, in a placebo- 60 years and older in Colorado, and found that older adults controlled trial that evaluated aerosolized cannabis, there were likely to report using cannabis for both recreational was a decline in pain ratings among patients with diabetic and medical purposes and generally thought cannabis had a peripheral neuropathy,8 and another study examining positive impact on their lives.22 Brown et al studied data in ® Sativex , an extract of 1:1 THC/CBD ratio, found cannabis the Florida Medical Marijuana Use Registry and found that to be associated with an improvement in self-reported sleep over half of those registered were older adults, and the most quality among chronic pain patients.9 Additionally, studies common reason for cannabis use was for chronic pain.23 show cannabis may serve a palliative role in cancer treat- There have been some studies including older adults that ment by ameliorating many of the adverse effects of chemo- examine how cannabis is used in California,24-26 a state therapy.10 Although it is clear more research is needed to where medical use has been legalized since 1996 and recrea- prove the potential benefits as well as harms of cannabis in tional use since 2016. For example, one survey among general and especially in older adults,11-15 it is possible can- patients in a San Francisco dispensary found that older nabis may serve as an effective treatment or palliative aid adults were less likely to report problematic cannabis con- for addressing difficult to treat conditions, such as pain and sumption practices compared with younger patients.24 insomnia, in older adults.16,17 However, most of these studies were sampled from the Indeed, epidemiological studies have shown an community or local dispensaries, and to the best of our increase in cannabis use among older adults. A study by knowledge, none has examined this in a geriatrics clinic Han and Palamar documented an increase in cannabis setting. use from 2.4% in 2015 to 4.2% in 2018 among adults More research is needed to delineate administration 65 years and older in the United States.18 There is also forms (e.g., smoking, tinctures, topicals), the health con- evidence for increased use of cannabis in earlier ditions and/or symptoms cannabis is being used to treat, years.19,20 the cannabinoid composition (e.g., CBD and THC), and Despite the increasing use of cannabis in older adults, potency and potential adverse effects experienced in this few studies have examined the ways in which cannabis is population. Additionally, more research is needed to used. Reynolds et al completed a survey among 345 patients examine this in a clinic population of older adults specifi- in a geriatrics clinic at the University of Colorado in 2016 cally within California. To address these gaps in the liter- to 2017 and found 32% of patients used cannabis at least ature, we conducted a survey at a geriatrics clinic at the once in their lifetimes, and the common reasons for canna- University of California, San Diego (UCSD), in La Jolla, bis use were for pain and sleep disorders.21 Lum et al con- CA, to obtain a more detailed picture of cannabis use in ducted a survey among community-dwelling adults aged these patients. JAGS JANUARY 2021-VOL. 69, NO. 1 CANNABIS USE IN OLDER ADULTS 93

Table 2. Cannabis Use Characteristics of Those Who Used Within Past 3 Years

Total Use between 6 mo and 3 y Use within previous 6 mo Characteristic (N = 83) (N = 27) (N = 56)

Use frequencya Daily 27 (38) 1 (4) 26 (54) Weekly 11 (15) 5 (21) 6 (12) Monthly 12 (17) 1 (4) 11 (23) Yearly or less 22 (31) 17 (71) 5 (10) CBD vs THC CBD-only products 37 (46) 12 (46) 25 (45) Products containing THC 33 (41) 9 (35) 24 (44) Not sure 11 (14) 5 (19) 6 (11) Use type Medical purposes only 63 (78) 20 (74) 43 (80) Recreational purposes only 6 (7) 4 (15) 2 (4) Both 12 (15) 3 (11) 9 (17) Where obtained cannabis productb Dispensary 45 (56) 18 (67) 27 (50) Grow own 3 (4) 0 (0) 3 (6) From someone else 21 (26) 8 (30) 13 (25) Delivery service 20 (25) 4 (15) 16 (30) Grocery store 2 (2) 1 (4) 1 (2) Healthcare provider 1 (1) 0 (0) 1 (2) Administration forms usedb Smoking 25 (30) 12 (44) 13 (24) Vaping concentrate (e.g., vape pen) 11 (13) 4 (15) 7 (13) Vaping ﬂower 3 (4) 0 (0) 3 (5) Edibles 21 (26) 8 (30) 13 (24) Patches 1 (1) 0 (0) 1 (2) Tinctures 29 (35) 11 (41) 18 (33) Pills 8 (10) 3 (11) 5 (9) Lotion 29 (35) 8 (30) 21 (38) Dabbing 0 (0) 0 (0) 0 (0) Suppository 0 (0) 0 (0) 0 (0) Who knows about useb Healthcare provider 34 (41) 8 (30) 26 (47) Family member 77 (94) 25 (93) 52 (95) Friends 41 (50) 13 (48) 28 (51) No one 3 (4) 1 (4) 2 (4) Unsure 3 (4) 1 (4) 2 (4)

Note: Data are given as number (percentage) of each group. Percentages correspond to column totals. Abbreviations: CBD, cannabidiol; THC, tetrahydrocannabinol. aStatistically signiﬁcant at P < .05 from chi-squared or Fisher exact tests. bIndividuals were asked to check as many response options as applicable for “Where obtained cannabis product,”“Administration forms used,” and “Who knows about use,” and therefore percentages do not add to 100%.

METHODS 85–89, and ≥89 years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, and Survey Development and Timing of Administration unknown), sex (male or female), marital status (married or We conducted an anonymous survey of patients seen in a long-term partner, widowed, divorced/separated, single, or geriatrics clinic at UCSD. The survey we used was based on never married), and highest level of education achieved two other surveys of cannabis use21,27 and informed by (high school or less, some/completed college degree, or feedback from clinicians and cannabis experts. Between graduate and/or advanced degree), followed by a question June 19, 2019, and June 24, 2019, we tested the survey to ascertain if the respondent had ever used cannabis or with 84 patients to assess clarity of questions and feasibility cannabis products. Those who answered “no” were of data collection procedures. The ﬁnal version of the sur- informed they had completed the survey and those answer- vey was administered between June 28 and September ing “yes” were asked further questions on cannabis use, 6, 2019. The survey was designed to be completed in less including: at what ages in their life they used cannabis than 10 minutes. (10–20, 21–40 years, etc), and the most recent time canna- The survey included questions on demographic infor- bis was used (within last 6 months, between 6 months and mation, including age (<65, 65–69, 70–74, 75–79, 80–84, 3 years, and >3 years ago). As recreational cannabis use 94 YANG ET AL. JANUARY 2021-VOL. 69, NO. 1 JAGS

Figure 1. Reasons for cannabis use among all users (N = 83). Note: Data label corresponds to N for each reason. Multiple reasons could be chosen. No patients reported use for Parkinson’s disease, epilepsy, multiple sclerosis, and posttraumatic stress disorder. The “other” category includes cancer, high blood pressure, itching, inflammation, and spinal cord injury. was legalized 3 years before the administration of our sur- were aged 75 years and older, 57% were female, and 79% vey, we asked those who reported use within the past were non-Hispanic White. Fifty-three percent were married/ 3 years further questions on cannabis use, including: pri- in a long-term relationship, and 85% had at minimum mary cannabinoid most commonly used (CBD or THC), some college education. reasons for use (medical, recreational, or both), source of cannabis acquisition (e.g., dispensary, growing own, or delivery service), frequency of use (daily, weekly, monthly, Data Analysis or yearly), method of use (e.g., edibles, smoking, tinctures, or patches), and others who are aware of patient’s use Analyses were completed in three stages. First, we focused (e.g., spouse, significant other, healthcare provider, family, on those who used cannabis within the past 3 years, and or friend). The survey also asked respondents if they had compared the demographic characteristics between those ever experienced negative adverse effects related to cannabis who used cannabis within past 6 months versus those who use and, if so, were asked to identify them from a list of used cannabis between 3 years and 6 months ago using chi- 11 choices and one open-ended response option. Respon- squared tests (or Fisher exact tests if cell sizes were too low dents were asked to indicate what conditions and/or symp- [<4 observations]). Second, we compared these groups for toms they used cannabis to treat from a list of the items on cannabis use, reported adverse effects, and rea- 15 conditions and symptoms, including one open-ended sons for use. Third, to explore lifetime patterns of cannabis response. For each condition/symptom selected, respondents use, we identified cannabis users who reported using canna- were asked to rate the helpfulness of cannabis for each bis for the first time as older adults (e.g., current cannabis (extremely, somewhat, minimally, or not at all helpful). users reporting no cannabis use before the age of 61 years) Please see Supplementary Material S1 for a copy of the and compared this group with those who previously used survey. cannabis. For these analyses, we used chi-squared or Fisher exact tests if cell sizes were too low.

Data Collection Procedures In the clinic, each patient was provided the survey by staff RESULTS when they checked in for a visit. Patients were informed Of the 568 patients who completed surveys, 56 (10%) used that the survey was anonymous, and that participation was cannabis within the past 6 months, 27 (5%) used cannabis voluntary. Patients completed the survey in the reception between 6 months and 3 years ago, 71 (13%) used canna- area and placed the survey in a locked box before entering bis greater than 3 years ago, and 414 (73%) were never an examination room. To determine the percentage of peo- users of cannabis products. Table 1 reports the demo- ple who completed the survey, patients were asked to return graphic information of cannabis users (herein deﬁned as the survey even if they did not complete it. This study was those using cannabis within the past 3 years). Most (79%) deemed exempt from institutional review board review by were between the ages of 65 and 84 years, over half (60%) the UCSD Institutional Review Board. were female, most (92%) were non-Hispanic White, over half were married or had a long-term partner (58%), and 89% reported at least some postsecondary education. No Participants differences in demographic characteristics were observed A total of 601 surveys were distributed, of which 568 were between those using cannabis within the past 6 months and completed (95%). Of those who completed surveys, 73% those using between 6 months and 3 years (Table 1). JAGS JANUARY 2021-VOL. 69, NO. 1 CANNABIS USE IN OLDER ADULTS 95

Table 3. Cannabis Use Characteristics Comparing Those Table 3 (Contd.) Who Used Cannabis for the First Time as Older Adults Used Used for first time as Versus Those Who Used Cannabis Earlier in Life in past older adult Characteristic (N = 32) (N = 50) Used Used for first time as in past older adult Patches 0 (0) 1 (2) Characteristic (N = 32) (N = 50) Tinctures 9 (28) 20 (41) Age, ya Pills 1 (3) 7 (14) a <65 1 (3) 1 (2) Lotion 7 (22) 22 (45) 65–74 18 (56) 12 (24) Dabbing 0 (0) 0 (0) 75–84 10 (31) 25 (50) Suppository 0 (0) 0 (0) b ≥85 3 (9) 12 (24) Who knows about use a Sex Healthcare provider 7 (22) 27 (55) Female 16 (50) 33 (66) Family member 30 (94) 46 (94) Male 16 (50) 17 (34) Friends 19 (59) 21 (43) Race/ethnicity No one 2 (6) 1 (2) Non-Hispanic White 31 (97) 44 (88) Unsure 2 (6) 1 (2) Non-Hispanic Black 0 (0) 1 (2) Note: Data are given as number (percentage) of each group. Percentages Hispanic 1 (3) 4 (8) correspond to column totals. Abbreviations: CBD, cannabidiol; THC, Non-Hispanic Asian 0 (0) 1 (2) tetrahydrocannabinol. Relationship status aStatistically significant at P < .05 from chi-squared or Fisher exact tests. Married or long-term 21 (66) 26 (52) bIndividuals were asked to check as many response options as applicable for partner “Where obtained cannabis product,”“Administration forms used,” and Widowed 5 (16) 15 (30) “Who knows about use,” and therefore percentages do not add to 100%. Divorced/separated 3 (9) 9 (18) Single, never married 3 (9) 0 (0) Education Table 2 describes the cannabis use characteristics of High school or less 2 (6) 7 (14) cannabis users within the past 3 years. Of the 83 users, Some/completed 15 (47) 20 (41) more than half reported daily or weekly cannabis use. college degree Forty-six percent reported using CBD-only products, and a Graduate and/or 15 (47) 22 (45) similar percentage reported using products containing advanced degree THC. Almost 80% reported using cannabis for medical Use frequency purposes only; six persons (7%) reported using cannabis Daily 8 (27) 18 (44) for recreational purposes only. Half of respondents Weekly 7 (23) 4 (10) obtained cannabis from a dispensary, with the next most Monthly 5 (17) 7 (17) common source being from a delivery service or another Yearly or less 10 (33) 12 (29) person. Only 14% reported obtaining cannabis from more a CBD vs THC than one source. Lotions and tinctures were the most com- CBD-only products 9 (28) 28 (57) mon methods of cannabis use, followed by smoking and Products containing 17 (53) 16 (33) edibles, with more than 37% reporting using more than THC one method of administration. Family members were most Not sure 6 (19) 5 (10) likely to know about cannabis use, followed by friends and Use typea healthcare providers, with 67% reporting more than one Medical purposes only 16 (52) 47 (94) group being aware of the respondent’s cannabis use. Those Recreational purposes 5 (16) 1 (2) only using cannabis within the past 6 months used more fre- Both 10 (32) 2 (4) quently as compared to those using between 6 months and Where obtained cannabis 3 years. productb Figure 1 shows the frequency of conditions and/or Dispensary 18 (56) 27 (55) symptoms for which respondents used cannabis. The most Grow own 3 (9) 0 (0) common conditions/symptoms reported were pain/arthritis From someone else 9 (28) 12 (25) (73%), sleep disturbance (29%), and anxiety (24%). On Delivery service 9 (28) 11 (22) average, over three-quarters of patients deemed cannabis Grocery store 1 (3) 1 (2) “somewhat” or “extremely” helpful in managing any of Healthcare provider 0 (0) 1 (2) these conditions. Just under 40% reported using cannabis Administration forms for more than one symptom/condition. Among the usedb 33 respondents who used cannabis for more than one Smokinga 19 (59) 5 (10) symptom/condition, the most common combinations were Vaping concentrate 5 (16) 6 (12) pain/arthritis and sleep conditions (24%), depression and (e.g., vape pen) anxiety (9%), and pain/arthritis, sleep, depression, and anx- Vaping flower 3 (9) 0 (0) iety (9%). a Edibles 14 (44) 7 (14) Twelve users (15%) reported experiencing adverse (Continues) effects, with the most common being dizziness (N = 5), 96 YANG ET AL. JANUARY 2021-VOL. 69, NO. 1 JAGS followed by anxiety (N = 3), dry mouth, panic attack, para- examining these potential drug-cannabis interactions is noia, unsteadiness, agitation, and other (N = 2 for each), warranted. and dry eyes and forgetfulness (N = 1 for each). Among At the same time, it is possible that cannabis may play those reporting adverse effects, individuals reported on a valuable role in deprescribing efforts of potentially inap- average 1.83 (standard deviation = 1.19) adverse effects. propriate medications for older adults. One survey with Of the 82 respondents who completed questions on 9,003 respondents showed that, of the 486 respondents ages in which cannabis was used during their lifetime, 61% who reported ever using cannabis and opioids in the past used cannabis for the first time as adults aged 61 years or year, 41% reported a decrease or cessation of opioid use older (Table 3). Compared with those who used cannabis due to cannabis use.30 Another cross-sectional survey indi- in the past, those who used cannabis for the first time as cated that cannabis is also being used to substitute for anxi- older adults were more likely to be older, use CBD-only olytics/benzodiazepines and antidepressant medications.31 It products, use cannabis for medical purposes, use lotions, is possible that cannabis, when used selectively and with and report their healthcare provider being aware of their proper supervision, may help decrease polypharmacy in cannabis use, and were less likely to consume cannabis via older persons, and be a potentially safer substitute for medi- smoking or via edibles (P < .05 for all). cines, including opioids and benzodiazepines, as well as improve quality of life. Under half of current users reported telling their DISCUSSION healthcare providers about their cannabis use. Past research has shown clinicians, for the most part, are supportive of With growing interest in the potential health benefits of cannabis for medical use, but they have reservations about cannabis and newer legislation favoring legalization across the limited evidence base, potential safety issues, and prod- more states, cannabis use is becoming more common in uct quality and effectiveness.32,33 A study by Baumbusch older adult populations. In this study, we described canna- et al found older adult cannabis users discussed cannabis bis use characteristics of patients seen in a geriatrics clinic with their healthcare providers; however, the main source in California, a state that has a long history of legalized of information they received was from nonclinical sources medical cannabis and more recent recreational use. Our (e.g., friends and media).34 Incorporating scientifically study showed that older adults use cannabis primarily for sound information about cannabis in health professionals’ medical purposes to treat a variety of common health con- curricula and ongoing professional education forums may ditions, including pain, sleep disturbances, and psychiatric help clinicians feel more comfortable discussing cannabis conditions. use with their patients. Including questions on cannabis use Our study findings show strikingly similar findings to as part of medication reconciliation during regular ambula- other geriatrics clinic-based studies in other states and in tory visits might also facilitate conversations with patients. community-based samples of older adults.21-23 Treatment Our study has several limitations. First, the sample size for pain was the most common reason for cannabis use, of current users was small (N = 83). Despite this, our study which is similar to the Reynolds21 and Brown23 studies provides some novel insights into cannabis use in older showing pain to be a major reason for use in older adults. Second, given the sensitivity of the topic, it is possi- populations. The Reynolds21 study also showed sleep prob- ble that respondents may have been reluctant to report can- lems to be a common reason for use. We also found three- nabis use due to stigma. However, we expect stigma was fourths reported cannabis being helpful for addressing minimal because the survey was anonymous and California health conditions and with few adverse effects, which con- has legalized cannabis for both medical and recreational firms findings from the study by Lum et al,22 also showing use. Third, our sample was seen in a clinic located in a rela- older adult users to find cannabis useful. tively affluent and highly educated community. Fourth, the Notably, as hemp-based CBD products become more survey was provided in English, and thus our survey only available across the United States, older adults who may be included people who understood this language. Fifth, concerned about the negative psychoactive effects of THC- respondents may not be representative of individuals receiv- containing products may be more willing to use cannabis ing care in other geographic areas or those within different products that contain primarily CBD and to use them in top- socioeconomic and demographic groups. Finally, these ical formulations. The recent introduction of CBD-only results may not be generalizable to states where recreational products may explain our finding that new users of cannabis or medical cannabis remains illegal. engaged in substantially less risky consumption practices In conclusion, our study has augmented what is known than those who used cannabis in the past (i.e., used cannabis about cannabis use in older adults by identifying distinct via lotions and tinctures rather than via edibles or smoking). patterns and characteristics of cannabis use among them, Given polypharmacy is common in older adults28 and with older adult cannabis users using cannabis primarily results showed cannabis was used primarily for medical for medical reasons and to treat specific conditions. These conditions, there is a need to determine the ways cannabis findings are particularly relevant as they provide an updated can interact with the commonly complex combination of picture of cannabis use in a clinic-based sample of older medications in this patient group. In the Brown et al study, adults in California. It will be important to continue moni- older adult cannabis patients were coprescribed a number toring population-based trends in cannabis use in older of other medications, including antidepressants, sedatives adults, and identify how the cannabis use characteristics (e.g., benzodiazepines), and opioids, among others.23 evolve as changes in legalization, availability, formulation, Higher doses of cannabinoids have the potential to affect and vehicle of administration occur and evidence of harm the metabolism of various medications,29 and thus research and benefit accrues. Further, it is imperative to better JAGS JANUARY 2021-VOL. 69, NO. 1 CANNABIS USE IN OLDER ADULTS 97 understand the efficacy and safety of different formulations 13. Pratt M, Stevens A, Thuku M, et al. Benefits and harms of medical cannabis: of cannabis in treating common conditions in older adults a scoping review of systematic reviews. Syst Rev. 2019;8(1):320. 14. van den Elsen GA, Ahmed AI, Lammers M, et al. Efficacy and safety of med- who are heterogeneous in their health and functional status ical cannabinoids in older subjects: a systematic review. Ageing Res Rev. to maximize benefit and minimize harm. 2014;14:56-64. 15. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456-2473. ACKNOWLEDGMENTS 16. Ancoli-Israel S, Ayalon L. Diagnosis and treatment of sleep disorders in older adults. Am J Geriatr Psychiatry. 2006;14(2):95-103. The authors thank Ian R. Reynolds, MD, Gretchen Orosz, 17. Larsson C, Hansson EE, Sundquist K, Jakobsson U. Chronic pain in older adults: prevalence, incidence, and risk factors. Scand J Rheumatol. 2017; MD, and coauthors for providing access to their survey on 46(4):317-325. cannabis use in older adults. 18. Han BH, Palamar JJ. Trends in cannabis use among older adults in the Financial Disclosure: This work was supported by the United States, 2015-2018. JAMA Intern Med. 2020;180(4):609-611. National Institute on Aging (T35AG026757, 19. Lloyd SL, Striley CW. Marijuana use among adults 50 years or older in the 21st century. Gerontol Geriatr Med. 2018;4:2333721418781668. K01AG061239, and P30AG059299), the National Institute 20. Han BH, Palamar JJ. Marijuana use by middle-aged and older adults in the on Drug Abuse (K23DA043651), the Stein Institute for United States, 2015-2016. Drug Alcohol Depend. 2018;191:374-381. Research on Aging, the Center for Healthy Aging, and the 21. Reynolds IR, Fixen DR, Parnes BL, et al. Characteristics and patterns of Division of Geriatrics and Gerontology at the University of marijuana use in community-dwelling older adults. J Am Geriatr Soc. 2018; 66(11):2167-2171. California, San Diego. 22. Lum HD, Arora K, Croker JA, et al. Patterns of marijuana use and health Conflict of Interest: The authors have no conflicts. impact: a survey among older Coloradans. Gerontol Geriatr Med. 2019;5: Author Contributions: Mr Yang, Dr Kaufmann, and 2333721419843707. Dr Moore contributed to study concept and design, acquisi- 23. Brown JD, Costales B, van Boemmel-Wegmann S, Goodin AJ, Segal R, Winterstein AG. Characteristics of older adults who were early adopters of tion of data, analysis and interpretation of data, and prepa- medical cannabis in the Florida medical marijuana use registry. J Clin Med. ration of manuscript. Ms Nafsu, Ms Lifset, and Dr Nguyen 2020;9(4):1166. contributed to acquisition of data and manuscript prepara- 24. Haug NA, Padula CB, Sottile JE, Vandrey R, Heinz AJ, Bonn-Miller MO. tion. Dr Sexton contributed to study concept and design, anal- Cannabis use patterns and motives: a comparison of younger, middle-aged, and older medical cannabis dispensary patients. Addict Behav. 2017;72: ysis and interpretation of data, and preparation of 14-20. manuscript. Drs Han and Kim contributed to preparation of 25. O’Connell TJ, Bou-Matar CB. Long term marijuana users seeking medical manuscript. cannabis in California (2001-2007): demographics, social characteristics, Sponsor’s Role: The sponsors of this study had no role patterns of cannabis and other drug use of 4117 applicants. Harm Reduct J. 2007;4:16. in the design, methods, subject recruitment, data collections, 26. Grella CE, Rodriguez L, Kim T. Patterns of medical marijuana use among analysis, and preparation of article. individuals sampled from medical marijuana dispensaries in Los Angeles. J Psychoactive Drugs. 2014;46(4):267-275. 27. 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